Essentials
NCPD Article

Chemotherapy-Induced Cognitive Impairment

Karen Kinsley

Wendy Pritchett

nursing interventions, patient education, chemobrain, cognitive impairment
CJON 2023, 27(2), 205-208. DOI: 10.1188/23.CJON.205-208

Terms such as “chemobrain” or “chemofog” may be familiar to many patients with cancer. Specific chemotherapy agents are known to cause chemotherapy-induced cognitive impairment (CICI). Interventions to prevent or reduce cognitive impairment can be helpful to patients. Nurses can make better assessments and individualized care plans by educating patients about the signs and symptoms of CICI.

Jump to a section

    Earn free contact hours: Click here to connect to the evaluation. Certified nurses can claim no more than 1 total ILNA point for this program. Up to 1 ILNA point may be applied to Care Continuum OR Nursing Practice OR Oncology Nursing Practice OR Symptom Management, Palliative Care, Supportive Care OR Quality of Life OR Treatment. See www.oncc.org for complete details on certification.

    Chemotherapy-induced cognitive impairment (CICI), also known as “chemobrain” or “chemofog,” can greatly affect the quality of life of a cancer survivor. Some chemotherapy agents can cause a peripheral inflammatory response that leads to brain changes and can result in cognitive impairment (Ren et al., 2017). About 75% of patients receiving chemotherapy have reported symptoms related to CICI, and about 35% of those patients have experienced such symptoms for months or years after treatment (Asher et al., 2019; Bompaire et al., 2017). Risk factors for CICI include cancer diagnosis at a younger age, menopause status, increasing age, and history of anxiety, depression, and alcohol abuse (Cascella et al., 2018). The most common symptoms related to CICI are problems with memory, attention, and speed of processing thoughts (Moore et al., 2019; Ren et al., 2017). CICI symptoms can be similar to symptoms that accompany accelerated aging syndromes. Some patients with CICI also report increased anxiety, fatigue, depression, or overall health decline (Cascella et al., 2018). Although there are many symptoms associated with CICI, anticipating or predicting CICI in advance is challenging.

    Chemotherapy Agents Associated With CICI

    Although it is unclear whether all chemotherapy agents cause CICI, some drugs have been found to affect cognitive function. Doxorubicin, a chemotherapy agent used to treat multiple cancers, contributes to neurotoxicity and can induce DNA damage, oxidative stress, and synaptic dysplasia (Ramalingayya et al., 2017). Cisplatin can cause neurologic changes in the brain that affect cognitive ability even at a reduced dose (Ongnok et al., 2020). A regimen consisting of the chemotherapy agents rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone, collectively referred to as R-CHOP, is commonly used to treat lymphoma and may also contribute to cognitive impairment (Portluck, 2017). Vincristine is a neurotoxic agent, and prednisone can cross the blood–brain barrier; thus, both agents can increase the risk of cognitive impairment along with the cognitive effects of doxorubicin (Ongnok et al., 2020). Other chemotherapy agents associated with CICI are methotrexate, 5-fluorouracil, carmustine, and cytarabine (Cascella et al., 2018).

    Interventions for Treatment of Cognitive Impairment

    Nonpharmacologic interventions may be used to treat cognitive impairment in patients receiving chemotherapy. Physical exercise may prevent or limit cognitive impairment. More physically active patients are less likely to develop memory loss or memory decline, which can present as initial symptoms of CICI (Salerno et al., 2021). Individuals who engage in moderate to vigorous physical exercise, such as aerobic exercise or strength exercise, may benefit through reduced cognitive impairment and improved quality of life (Witlox et al., 2019). In addition, a diet high in omega-3 fatty acids and low in added sugar has been shown to reduce inflammation and oxidative stress and increase neural protection toward mitigating cognitive impairment in animal models (Orchard et al., 2017). Overall, patients who maintain a healthy lifestyle and weight and engage in physical exercise may be able to prevent or reduce cognitive impairment (Orchard et al., 2017; Witlox et al., 2019).

    Cognitive training is another nonpharmacologic strategy that reduces cognitive impairment (Bray et al., 2016). Cognitive training restores cognitive function through repeated and structured tasks that challenge a patient to perform problem-solving (Sitzer et al., 2006). Examples of cognitive training are detecting patterns or memorizing tasks or lists for 30–50 minutes twice a week (Floyd et al., 2021) (see Figure 1).

    FIGURE1

    An additional nonpharmacologic approach with promising evidence to combat CICI is acupuncture. A randomized controlled trial that compared electroacupuncture trigeminal nerve stimulation plus body acupuncture to body acupuncture alone in 93 patients with breast cancer who had CICI found greater improvement in CICI and memory loss in the electroacupuncture and body acupuncture treatment group (Zhang et al., 2020). This group also had improvement in gastrointestinal, neurologic, and distress-related symptoms. Each group received two sessions of acupuncture or electroacupuncture per week for eight weeks (Zhang et al., 2020). 

    Methylphenidate and modafinil are psychostimulant medications used in the treatment of Alzheimer disease and can be administered to treat memory loss in cancer survivors with CICI (Cascella et al., 2018). Studies suggest enhanced memory and attention skills in cancer survivors who received either of these medications. In addition, methylphenidate improved cancer-related fatigue (Cascella et al., 2018). Tachycardia, hypertension, nausea, and anxiety are possible side effects of methylphenidate, and anxiety, headache, and nausea are possible side effects of modafinil. The dosing and frequency of these medications are monitored by the patient’s clinical care team. In addition, patients can consult with their clinical care teams to ensure that the best possible options are being considered to improve their quality of life.

    Implications for Nursing

    Patient and caregiver education is a priority in the nursing care of patients with CICI. Although it is difficult to predict when or whether CICI will occur, education about the signs and symptoms of CICI (forgetfulness, confusion, memory impairment) needs to be provided prior to chemotherapy. Encouraging cancer survivors to maintain a healthy lifestyle inclusive of getting adequate physical exercise and maintaining a healthy weight are opportunities for the patient to actively improve their quality of life and potentially reduce the severity of cognitive impairment (Asher et al., 2019). When available, a dietitian can be consulted to work with the patient in monitoring weight gain or loss.

    The continued and supportive patient and caregiver education provided by the nurse can assist in reducing the anxiety resulting from CICI. Nurses can discuss with cancer survivors and their caregivers the sharing of episodes of forgetfulness or slower thinking. The caregiver’s knowledge of the symptoms of CICI can assist in early intervention and follow-up with the clinical team.

    When a patient presents to the cancer center for follow-up or treatment visits, the nurse can evaluate the patient for signs and symptoms of forgetfulness and confusion. Although cognitive deficits may warrant further diagnostic examinations to rule out other conditions such as brain metastasis, these assessments can guide the clinical care team in planning the care of the patient in addition to providing support to the caregivers.

    FIGURE2

    Forgetfulness and confusion can be frustrating for a patient; thus, it is important that the nurse be calm and patient when communicating. In addition, the nurse can provide the patient with simple physical exercises and cognitive training activities to potentially reduce cognitive impairment. It is important to follow up with the patient to learn whether these interventions have improved CICI symptoms. Each patient may have a different response to interventions, so continued communication and assessment will aid in individualizing their care (see Figure 2).

    TEST

    Conclusion

    Specific chemotherapy agents are associated with CICI. A healthy lifestyle may prevent the development or reduce the severity of CICI. For patients who experience CICI, treatment should be individualized based on their symptoms. The nurse is a valuable resource for CICI patient education and assessment and can advocate with the care team for interventions such as cognitive training and exercise plans.

    About the Authors

    Karen Kinsley, MSN, RN, OCN®, is a clinical nurse III at Memorial Sloan Kettering Cancer Center in New York, NY; and Wendy Pritchett, MSN, RN, OCN®, is a nurse manager at Overlook Medical Center in Summit, NJ. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. Kinsley can be reached at k.kinsley1821@gmail.com, with copy to CJONEditor@ons.org.

    References

    Asher, A., Van Dyk, K., Jo, M.-Y., Bailey, C., & Myers, J.S. (2019). Cancer-related cognitive impairment: Retrospective analyses of a multidimensional, psychoeducation-based cognitive rehabilitation intervention. Clinical Journal of Oncology Nursing, 23(3), 301–308. https://doi.org/10.1188/19.CJON.301-308

    Bompaire, F., Durand, T., Léger-Hardy, I., Psimaras, D., & Ricard, D. (2017). Chemotherapy-related cognitive impairment or “chemobrain”: Concept and state of art. Geriatrie et Psychologie Neuropsychiatrie du Vieillissement, 15(1), 89–98. https://doi.org/10.1684/pnv.2017.0659

    Bray, V.J., Dhillon, H.M., Bell, M.L., Kabourakis, M., Fiero, M.H., Yip, D., . . . Vardy, J.L. (2016). Evaluations of a web-based cognitive rehabilitation program in cancer survivors reporting cognitive symptoms after chemotherapy. Journal of Clinical Oncology, 35(2), 217–225. https://doi.org/10.1200/jco.2016.67.8201

    Cascella, M., Di Napoli, R., Carbone, D., Cuomo, G.F., Bimonte, S., & Muzio, M.R. (2018). Chemotherapy-related cognitive impairment: Mechanisms, clinical features and research perspectives. Recenti Progressi in Medicina, 109(11), 523–530. https://doi.org/10.1701/3031.30289

    Floyd, R., Dyer, A.H., & Kennelly, S.P. (2021). Non-pharmacological interventions for cognitive impairment in women with breast cancer post-chemotherapy: A systematic review. Journal of Geriatric Oncology, 12(2), 173–181. https://doi.org/10.1016/j.jgo.2020.05.012

    Moore, K., Stutzman, S., Priddy, L., & Olson, D. (2019). Chemobrain: A pilot study exploring the severity and onset of chemotherapy-related cognitive impairment. Clinical Journal of Oncology Nursing, 23(4), 411–416. https://doi.org/10.1188/19.CJON.411-416

    National Comprehensive Cancer Network. (2022). NCCN Guidelines® insights: Survivorship (version 1.2022). https://doi.org/10.6004/jnccn.2022.0052

    Ongnok, B., Chattipakorn, N., & Chattipakorn, S.C. (2020). Doxorubicin and cisplatin induced cognitive impairment: The possible mechanisms and interventions. Experimental Neurology, 324, 113118. https://doi.org/10.1016/j.expneurol.2019.113118

    Orchard, T.S., Gaudier-Diaz, M.M., Weinhold, K.R., & DeVries, A.C. (2017). Clearing the fog: A review of the effects of dietary omega-3 fatty acids and added sugars on chemotherapy-induced cognitive deficits. Breast Cancer Research and Treatment, 161(3), 391–398. https://doi.org/10.1007/s10549-016-4073-8

    Portlock, C.S. (2017). How should you treat a patient with lymphoma who developed “chemobrain” after RCHOP therapy? ASH Clinical News. https://ashpublications.org/ashclinicalnews/news/3475/How-should-you-tr…

    Ramalingayya, G.V., Cheruku, S.P., Nayak, P.G., Kishore, A., Shenoy, R., Rao, C.M., & Krishnadas, N. (2017). Rutin protects against neuronal damage in vitro and ameliorates doxorubicin-induced memory deficits in vivo in Wistar rats. Drug Design, Development and Therapy, 11, 1011–1026. https://doi.org/10.2147/dddt.s103511

    Ren, X., St. Clair, D.K., & Butterfield, D.A. (2017). Dysregulation of cytokine mediated chemotherapy induced cognitive impairment. Pharmacological Research, 117, 267–273. https://doi.org/10.1016/j.phrs.2017.01.001

    Salerno, E.A., Culakova, E., Kleckner, A.S., Heckler, C.E., Lin, P.-J., Matthews, C.E., . . . Janelsins, M.C. (2021). Physical activity patterns and relationships with cognitive function in patients with breast cancer before, during, and after chemotherapy in a prospective, nationwide study. Journal of Clinical Oncology, 39(29), 3283–3292. https://doi.org/10.1200/jco.20.03514

    Sitzer, D.I., Twamley, E.W., & Jeste, D.V. (2006). Cognitive training in Alzheimer’s disease: A meta-analysis of the literature. Acta Psychiatrica Scandinavica, 114(2), 75–90. https://doi.org/10.1111/j.1600-0447.2006.00789.x

    Vance, D.E., Frank, J.S., Bail, J., Triebel, K., Niccolai, L.M., Gerstenecker, A., & Meneses, K. (2017). Interventions for cognitive deficits in breast cancer survivors treated with chemotherapy. Cancer Nursing, 40(1), E11–E27. https://doi.org/10.1097/jnn.0000000000000171

    Witlox, L., Schagen, S.B., de Ruiter, M.B., Geerlings, M.I., Peeters, P.H.M., Koevoets, E.W., . . . Monninkhof, E.M. (2019). Effect of physical exercise on cognitive function and brain measures after chemotherapy in patients with breast cancer (PAM study): Protocol of a randomized controlled trial. BMJ Open, 9(6), e028117. https://doi.org/10.1136/bmjopen-2018-028117

    Zhang, Z.-J., Man, S.-C., Yam, L.-L., Yiu, C.Y., Leung, R.C.-Y., Qin, Z.-S., . . . Dong, Y.-Y. (2020). Electroacupuncture trigeminal nerve stimulation plus body acupuncture for chemotherapy-induced cognitive impairment in breast cancer patients: An assessor-participant blinded, randomized controlled trial. Brain, Behavior, and Immunity, 88, 88–96. https://doi.org/10.1016/j.bbi.2020.04.035